Jamie R. Litvack

Determinants of outcomes of sinus surgery: A multi-institutional prospective cohort study

OBJECTIVES: 1) To measure the proportion of patients with chronic rhinosinusitis (CRS) who experience clinically significant improvement after endoscopic sinus surgery (ESS) in a prospective, multi-institutional fashion. 2) To identify preoperative characteristics that predict clinically significant improvement in quality of life (QOL) after ESS. STUDY DESIGN: Prospective, multi-institutional cohort study. SETTING: Academic tertiary care centers. SUBJECTS AND METHODS: A total of 302 patients with CRS from three centers were enrolled between July 2004 and December 2008 and followed for an average of 17.4 months postoperatively. Preoperative patient characteristics, CT scan, endoscopy score, and pre- and postoperative quality of life (QOL) data were collected. Univariate and multivariate analyses were performed. RESULTS: Patients improved an average of 15.8 percent (18.9 points) on the Rhinosinusitis Disability Index and 21.2 percent (21.2 points) on the Chronic Sinusitis Survey (both P < 0.001). Patients significantly improved on all eight Medical Outcomes Study Short Form-36 (SF-36) subscales (all P < 0.001). Among patients with poor baseline QOL, 71.7 percent of patients experienced clinically significant improvement on the RSDI and 76.1 percent on the CSS. Patients undergoing primary surgery were 2.1 times more likely to improve on the RSDI (95% confidence interval [CI], 1.2, 3.4; P = 0.006) and 1.8 times more likely to improve on the CSS (95% CI, 1.1, 3.1; P = 0.020) compared with patients undergoing revision surgery. CONCLUSION: In this prospective, multi-institutional study, most patients experienced clinically significant improvement across multiple QOL outcomes after ESS. Specific patient characteristics provided prognostic value with regard to outcomes.

Predictors of Olfactory Dysfunction in Patients With Chronic Rhinosinusitis

Objectives: To measure the prevalence of and identify clinical characteristics associated with poor olfactory function in a large cohort of patients with chronic rhinosinusitis (CRS).

Olfactory function and disease severity in chronic rhinosinusitis

Background Olfactory dysfunction is deemed to be a significant contributor to poor quality of life (QOL). However, little is known about the relationship of olfactory testing to other measures of disease burden in patients with chronic rhinosinusitis (CRS). In this study, we examine the relationship of olfactory function to computed tomography (CT) scores, endoscopy scores, and QOL measures in patients with CRS. Methods A multi-institutional, cross-sectional analysis of 367 patients was performed. Several objective measures were collected: the Smell Identification Test, Lund-MacKay CT score, Lund-Kennedy endoscopy score, two validated disease-specific QOL instruments, the Rhinosinusitis Disability Index and the Chronic Sinusitis Survey, and a general health-related QOL instrument, the Medical Short Form-36. Analysis of variance was performed. Correlation coefficients were calculated. Results Patients with olfactory dysfunction had significantly worse mean endoscopy scores (normosmics, 4.16 [± 3.97]; hyposmics, 6.26 [± 4.21]; anosmics, 9.61 [± 4.48]; p < 0.001) and significantly worse CT scores (normosmics, 9.11 [± 5.40]; hyposmics, 11.16 [± 5.96]; anosmics, 17.62 [± 5.37]; p < 0.001). Endoscopy scores were moderately correlated with olfactory scores (r = -0.46; 95% CI, -0.38, -0.54; p < 0.001). CT scores were moderately correlated with olfactory scores (r = -0.53; 95% CI, -0.45, -0.60; p < 0.001). Olfactory function was not correlated with disease-specific or general health-related QOL measures. Conclusion Although previous studies have suggested that olfactory impairment is associated with poor QOL, this study found no such correlation. In contrast, olfaction scores correlated well with other objective measures of CRS, namely, endoscopy and CT scores.

Does olfactory function improve after endoscopic sinus surgery

Objective: To examine the impact of endoscopic sinus surgery (ESS) on olfactory impairment in patients with chronic rhinosinusitis (CRS) over intermediate and long-term follow-up. We hypothesized that patients with mild olfactory dysfunction (hyposmia) would benefit from ESS, whereas patients with severe olfactory dysfunction (anosmia) would not. Study Design: Prospective, multi-institutional cohort study. Subjects and Methods: A total of 111 patients presenting for ESS for treatment of CRS were examined preoperatively, and at 6 and 12 months postoperatively. Demographic, comorbidity, and Smell Identification Test (SIT) data were collected at each time point. Univariate and multivariate analyses were performed. Results: The prevalence of gender-adjusted olfactory dysfunction prior to surgery was 67.5 percent. Surprisingly, hyposmic patients did not significantly improve after surgery. In contrast, patients with anosmia significantly improved after ESS (baseline, 6-month SIT scores: 9.7 ± 2.0, 21.3 ± 11.2; P = 0.001). Improvement was sustained at 12-month follow-up (21.7 ± 10.7; P = 0.001). Multivariate linear regression analysis showed that baseline olfactory category and nasal polyposis were significantly associated with improvement in postoperative olfactory function (P = 0.035, P = 0.002). Conclusion: Contrary to our hypotheses, patients with severe olfactory dysfunction significantly improved after ESS and sustained improvement over time, whereas patients with mild olfactory dysfunction did not.

Effects of depression on quality of life improvement after endoscopic sinus surgery.

Objectives/Hypothesis: To determine whether self‐ reported depression predicts lesser postoperative improvement in health‐related quality of life (HRQoL) after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS).

Correlations Between Endoscopy Score and Quality of Life Changes After Sinus Surgery

OBJECTIVE To assess whether change in endoscopy score correlates with change in health-related quality of life (HRQOL) following endoscopic sinus surgery for chronic rhinosinusitis. DESIGN Prospective open cohort. SETTING Tertiary rhinology clinic. PATIENTS One hundred two adult patients with and without nasal polyposis who elected to undergo endoscopic sinus surgery and were followed up for 12 +/- 2 months postoperatively. INTERVENTION Patient characteristics and Lund-Mackay computed tomography scores were recorded preoperatively. Lund-Kennedy endoscopy scores and 2 HRQOL surveys, the Rhinosinusitis Disability Index and Chronic Sinusitis Survey, were examined before and after surgery. MAIN OUTCOME MEASURES Postoperative changes in endoscopy score and HRQOL were examined using bivariate and multivariate analyses. RESULTS Statistically significant improvements were found in endoscopy score (P < .001) and for all total and subscale HRQOL measures (P < .001). After controlling for baseline status and comorbid factors, improvement in endoscopy score significantly correlated with 12-month improvement on the total Rhinosinusitis Disability Index (P = .01), the physical (P = .01) and functional (P = .02) subscales of the Rhinosinusitis Disability Index, and the symptom subscale of the Chronic Sinusitis Survey (P = .003) but could explain only 25.5% to 36.6% of the linear variation for these HRQOL improvements. CONCLUSIONS For most patients, endoscopy scores and disease-specific HRQOL significantly improve after endoscopic sinus surgery. Changes in endoscopy scores explain a portion of the improvement in HRQOL. For patients with chronic rhinosinusitis, improvements in disease-specific HRQOL outcomes are complex, multidimensional constructs that cannot be entirely explained by surgical changes measured by endoscopic examination. Trial Registration clinicaltrials.gov Identifier: NCT00799097.

Comparison of disease-specific quality-of-life instruments in the assessment of chronic rhinosinusitis

Many disease‐specific, quality‐of‐life (QOL) instruments exist for chronic rhinosinusitis (CRS), resulting in confusion about the best application and use of each instrument. We hypothesized that the most prevalently utilized instruments do not strongly correlate in all domains, but rather act in complementary fashion for QOL assessment.

Endoscopic and Quality‐of‐Life Outcomes After Revision Endoscopic Sinus Surgery

Objectives: First, to examine the impact of endoscopic sinus surgery (ESS) on endoscopic and quality‐of‐life (QOL) outcomes after revision ESS as compared to primary ESS. Second, to evaluate whether or not other risk factors and/or co‐morbidities influence the relationship between revision surgery status and outcomes of ESS.

Recurrent acute rhinosinusitis: Presentation and outcomes of sinus surgery

Background Patients with recurrent acute rhinosinusitis (RARS) represent a challenging subset of patients with rhinosinusitis. Data regarding the outcomes of care for these patients is extremely limited. The purpose of this study was to evaluate objective and patient-based measures in patients diagnosed with RARS before and after surgical intervention. Methods A prospective, nested case-control study was performed. Cases of RARS (n = 22) were matched to patients with chronic rhinosinusitis (CRS) without polyposis (n = 22) by age, sex, and race/ethnicity. Preoperative computed tomography (CT) and pre- and postoperative endoscopic examinations, the Chronic Sinusitis Survey, and the Rhinosinusitis Disability Index were scored and compared between cases and controls. Results Patients with RARS were less likely to have asthma or previous sinus surgery. Patients with CRS underwent more extensive surgery. There were no significant differences in preoperative CT, endoscopy, or patient-based, quality-of-life (QOL) scores. Both groups showed statistically significant improvements in total postoperative QOL scores. Patients with CRS showed significant improvement on endoscopy scores. Patients with RARS used significantly fewer sinus medications after endoscopic sinus surgery. Conclusion Patients with RARS were more often primary surgical patients and underwent less extensive surgery than their CRS counterparts. Both groups reported improved QOL after surgery.

Model building, effect modification, and outcomes after sinus surgery

We appreciate the thoughtful and analytical approach taken by Dr Chao in response to our article. He correctly points out that if olfactory function (X1) was binary, then the model would need the modifications set forth in the appendix. However, multiple model building approaches exist. In our analysis, we accounted for olfactory function as a categorical variable and our original conclusions hold true. Interestingly, in both models, there was a significant interaction between nasal polyposis and olfaction with regard to olfactory outcomes: anosmic patients with nasal polyposis improved to a greater extent than anosmic patients without nasal polyposis. We have also observed an interaction, or effect modification, with nasal polyposis and other clinical variables in the measurement of post–endoscopic sinus surgery (ESS) improvement. For example, patients with nasal polyposis and a history of prior sinus surgery are as likely to improve on endoscopy scores after ESS as patients undergoing primary surgery. Patients without nasal polyposis and a history of prior ESS are 3.9 times as likely to improve on endoscopic exam after ESS as primary patients. The differences observed in patients with nasal polyposis illustrate the heterogeneity of patients with chronic rhinosinusitis undergoing ESS. Some findings are likely related to the underlying constructs of the instruments used to measure the outcomes of ESS. However, it is also evident that patients with nasal polyposis behave differently than patients without nasal polyposis. As we learn more about the underlying nature of nasal polyposis and continue to study the clinical behavior of these patients, we will also better understand how this dynamic impacts the outcomes of ESS. Jamie R. Litvack, MD, MS Jess Mace, MPH Timothy L. Smith, MD, MPH Division of Rhinology and Sinus Surgery, Oregon Sinus Center Department of Otolaryngology–Head and Neck Surgery Oregon Health & Science University, Portland, OR REFERENCES